State of Illinois Eye Examination Report

State of Illinois
Eye Examination Report
Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides eye
examinations be submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school for
other children. The examination must be completed within one year prior to the first day of the school year the child enters the Illinois
school system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school.
Student Name ________________________________________________________________________________________________
(Last) (First) (Middle Initial)
Birth Date ____________________ Gender ______ Grade _____
(Month/Day/Year)
Parent or Guardian ____________________________________________________________________________________________
(Last)
(First)
Phone ______________________________
(Area Code)
Address _____________________________________________________________________________________________________
(Number) (Street) (City) (ZIP Code)
County ____________________________________________
To Be Completed By Examining Doctor
Case History
Date of exam ________________
Ocular history: ❑ Normal or Positive for ___________________________________________________________________
Medical history: ❑ Normal or Positive for ___________________________________________________________________
Drug allergies: ❑ NKDA or Allergic to ____________________________________________________________________
Other information _____________________________________________________________________________________________
Examination
Distance
Near
Right Left Both Both
Uncorrected visual acuity 20/ 20/ 20/ 20/
Best corrected visual acuity 20/ 20/ 20/ 20/
Was refraction performed with dilation? ❑ Yes ❑ No
Normal Abnormal Not Able to Assess Comments
External exam (lids, lashes, cornea, etc.) ❑ ❑ ❑ __________
Internal exam (vitreous, lens, fundus, etc.) ❑ ❑ ❑ __________
Pupillary reflex (pupils) ❑ ❑ ❑ __________
Binocular function (stereopsis) ❑ ❑ ❑ __________
Accommodation and vergence ❑ ❑ ❑ __________
Color vision ❑ ❑ ❑ __________
Glaucoma evaluation ❑ ❑ ❑ __________
Oculomotor assessment ❑ ❑ ❑ __________
Other _________________________ ❑ ❑ ❑ __________
NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.
Diagnosis
❑ Normal ❑ Myopia ❑ Hyperopia ❑ Astigmatism ❑ Strabismus ❑ Amblyopia
Other _______________________________________________________________________________________________________
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State of Illinois
Eye Examination Report
Recommendations
1. Corrective lenses: ❑ No ❑ Yes, glasses or contacts should be worn for:
❑ Constant wear ❑ Near vision ❑ Far vision
❑ May be removed for physical education
2. Preferential seating recommended: ❑ No ❑ Yes
Comments ________________________________________________________________________________________________
_________________________________________________________________________________________________________
3. Recommend re-examination: ❑ 3 months ❑ 6 months ❑ 12 months
❑ Other ____________________________________
4. _________________________________________________________________________________________________________
5. _________________________________________________________________________________________________________
Print name____________________________________________
Optometrist or physician (such as an ophthalmologist)
who provided the eye examination ❑ MD ❑ OD ❑ DO
Address ____________________________________________
____________________________________________
License Number_____________________________________
Consent of Parent or Guardian
I agree to release the above information on my child
or ward to appropriate school or health authorities.
(Parent or Guardian’s Signature)
Phone
____________________________________________
(Date)
Signature ____________________________________________
Date ___________________
(Source: Amended at 32 Ill. Reg. _________, effective ___________)
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Printed by Authority of the State of Illinois
6/09
IOCI1271-09